Authorization denial question

Authorization denial question

Tracy Fields

4/30/2021

Good morning everyone,

Hope you all have had a good week and are ready for the weekend.

I would greatly appreciate your opinions on an authorization denial for a
few codes that I have received for a preparatory prosthesis.

They are stating it is per the LCD guidelines to which I have read them
over and over and what they are claiming is not anywhere that I read. Also,
these are codes that have been billed to Medicare on other similar patients
and there is never an issue with them.

Please see the denial rationale below and give your thoughts if able.

*We've denied the medical services/items listed below requested by you or
your provider:*

*Some add on prosthesis components; the total contact feature, a molded end
cushion and an alignable system *

*Why did we deny your request? *
*We denied the medical services/items listed above because: *
*The request for authorization for a preparatory lower extremity prosthesis
(L5540) and most associated components is approved as the criteria for
medical necessity has been met. However, the request for the total contact
feature (L5637) is denied. The total contact feature is included as a part
of the preparatory prosthesis socket because the preparatory prosthesis is
used to help the residual limb mature before fitting an amputee with a
definitive prosthesis. Therefore, this addition code (L5637) is not
reasonable or necessary for use on a preparatory prosthesis and is denied.
The request for the molded lower (distal) end cushion (L5668) is denied.
The approved code (L5679) is approved and has a gel liner that provides the
extra cushion needed at the end of the residual limb. The request for
(L5668) is not medically necessary when paired with gel liner (L5679). The
request for the alignable system (L5910) is also denied. Your preparatory
prostheses is to be used for 30 days; and is a non-alignable system. The
preparatory prosthesis will need changes based on your new pattern of
walking. The alignable system (L5910) is not reasonable or necessary to use
with a preparatory prosthesis. The remaining codes are approved. We based
this decision on the Medicare Local Coverage Determination (LCD): Lower
Limb Prostheses (L33787). *

Appreciate your help.

Hope you have a wonderful weekend.

Thank you


*Tracy Fields*
Billing Specialist

*First Step Prosthetics*

*Kentucky Location:*

1136 US 31W Bypass, Bowling Green, KY 42101
Phone 270.904.6130 / Fax 270.721.0749

*Tennessee Location:*

728 Nashville Pike, Gallatin, TN 37066
Phone 615.461.8557 / Fax 615.461.8581

Email: <Email Address Redacted>


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